Physical Agents and Manual Therapy Techniques

Physical Agents Overview ~

These are classified by the tissue response to treatment (ex. Thermal changes caused by heating or cooling agents) or based on the type of energy used in the agent (ex. Ultrasound, electrotherapy).

Therapeutic benefits include pain management, increased flexibility and muscle strength, improved ROM, and healing. 

The decision to use physical agents as a direct intervention is based on a thorough examination of the patient’s symptoms, the desired outcomes, and the therapist’s knowledge of the physiological and clinical effects of each physical agent.

Physical Agents: Thermal Agents ~

Inflammation and repair stages of tissue healing can be altered through the use of thermal agents or electrical stimulation.

Thermal agents are used to modify the temperature of surrounding tissue and result in a change in the amount of blood flow to the injured area. They also affect the metabolism of the surrounding tissue and alter neuromuscular and connective tissue. The healing process can be accelerated and the injured tissue restored to optimal strength and integrity.

The extent of the therapeutic changes depends on the intensity of the thermal agent applied, the length of time the tissue is exposed to the agent, and the characteristics of the tissue being treated. The therapist must continually monitor and re-examine the patient to ensure that the thermal agent is appropriate and that the treatment outcomes are being achieved.

Thermal agents can be classified as those that provide superficial heat, deep heat, or cold.

Superficial Heat:

Superficial heat modalities create an increase in blood flow to cutaneous tissue close to the surface of the skin and are effective in reducing pain and stiffness, increasing ROM, and promoting healing.

Hot Pack - This is a pouch filled with silica gel and soaked in thermostatically controlled water. They are applied to the affected body part with layers of towels to prevent overheating.

Paraffin Treatment - involves dipping a patient’s involved extremity (normally hands or feet) into a mix of melted paraffin wax and mineral oil that is maintained at a temp of ~135 degrees Fahrenheit/~57 Celsius. The heat produces a relaxing pain-reducing effect which leaves skin warm and soft, increasing comfort when ROM exercises are performed.

Hydrotherapy - the use of water, can assist with wound healing

Fluidotherapy - the use of a self-contained unit filled with corn cobs finely chopped into a sawdust-type substance, heated to the desired temperature and circulated by air pressure around the involved body part. Patients can still exercise while the treatment is happening.

Whirlpool - can be used when the body part/entire body is immersed in a tank of water. Various tank sizes are used, from small ones for extremities to full-body (Hubbard) tanks.

Deep Heat:

Deep heat modalities produce physiologic effects similar to those of superficial heat agents but at a greater tissue depth that helps patients with deep muscle or joint dysfunction.

Thermal Ultrasound - a therapeutic application of high-frequency sound waves that penetrate tissue and increase tissue temperature to promote healing and reduce pain.

Short-wave Diathermy - uses electromagnetic energy to produce deep therapeutic heating effects.

Therapeutic cold (cryotherapy): a decrease of tissue temperature and thus blood flow and metabolism, resulting in a decrease in swelling and pain. 

Cryotherapy is the physical agent of choice for patients who have acute injuries with symptoms of swelling, pain, or both. 

Cold may be incorporated into a treatment protocol after exercise to reduce post-exercise soreness.

Commercial cold packs, ice massage, cold whirlpool, or cold used in conjunction with compression.

Physical Agents II ~

Electrical Stimulation:

Electrodes are placed on the skin at specific locations to stimulate nerves, muscles, and other soft tissues in an attempt to reduce pain and swelling, increase strength and ROM, and facilitate wound healing.

The therapist must have a clear understanding of the desired effects of the electrical stimulation intervention and have knowledge of appropriate parameters to use with regard to treatment intensity, voltage, and current type.

Other Physical Agents:

Additional physical agents include mechanical traction, hyperbaric oxygen, biofeedback, LASER therapy, and UV treatment.

They are used to decrease patient’s pain, promote healing, or improve strength, or motion in an attempt to maximize function.

Manual Therapy Techniques ~

These are a variety of manual techniques that are frequently used by orthopedic PTs, many of these techniques are used in current clinical research to validate and clarify their purpose and clinical efficacy.

Soft Tissue Mobilization (STM) Overview:

Include a variety of “hands-on” techniques designed to improve movement and function by restoring extensibility to the right tissue. They are designed to reduce pain or swelling and relax muscle ot fascial tension to create proper postural alignment and optimal muscle function.

Massage: (STM)

Involves a systematic use of various manual strokes to produce certain physiological, mechanical, and psychological effects. 

Swedish massage stroke promotes relaxation by decreasing pain or swelling, relieving tension, and improving the metabolism of surrounding tissues.

More vigorous massage strokes may be used before physical activity to stimulate and prepare the muscles for extension. 

Transverse friction massage is another soft tissue technique that is useful for promoting proper healing and improving the flexibility and function of soft tissues such as muscles, ligaments, and tendons.

Myofascial Release: (STM)

This involves manual stretching of the layers of the body’s fascia, which is the connective tissue surrounding muscle and other soft tissue. 

Myofascial release techniques soften and reduce restrictions in muscles and fascia that are limiting normal movement.

Joint Mobilization:

This is used when a patient’s dysfunction is the result of joint stiffness or hypomobility. 

The therapist applies specific passive movements of carrying amplitude to a joint, in either oscillatory (rhythmic, repeated movements) or in a sustained manner.

Joint mobilization techniques are used to reduce pain and stiffness affecting movement and restore normal joint motion.

Therapeutic Exercises ~

Forms the core of most rehabilitation programs. The goals of therapeutic exercise are not only to return normal function to an individual but also to prevent an initial injury, to educate the patient on how to prevent injury recurrence and to help maintain normal function.

These techniques can be used to improve ROM, strength, flexibility, balance + coordination, cardiovascular endurance, and function. 

The level of sophistication of an exercise program should not be determined by the type of equipment the clinic has since some of the most sophisticated exercises can be performed with expensive equipment.

ROM:

PROM: may be provided manually by the therapist or mechanically by a machine. This type of exercise can be used with bed rest patients or have paralysis of one or more limbs, or when AROM is contraindicated.

AROM: is subdivided into active assisted movement and active resisted movement. 

In active assisted the patient may be assisted manually or mechanically if the prime muscle mover is weak.

Pendulum exercises in which the patient does not receive any support or resistance are examples of active free exercises.

In active resisted exercises an external force resists the movement.

Resistance:

A form of active movement in which some form of resistance is provided. The goal is to increase muscular strength, endurance, and power.

Muscular strength is the maximal amount of tension an individual can produce in one repetition.

If the goal is to increase strength: the program focuses on low reps with heavy resistance.

Muscle endurance is the ability to produce and sustain tension over a prolonged period of time.

If the goal is to increase resistance the program focuses on using low resistance for high repetitions.

Muscle power is the amount of work produced by the muscle in a given amount of time.

If the goal is to increase power: the program focuses on explosive high-intensity muscle activity like jumping.

Resistance exercises can be categorized into three types, isometric, isotonic, and isokinetic. A combination of all three types is typically necessary to perform any functional activity.

Manual resistance can be applied to isolated muscle groups (MMT) or to a pattern of movement that involves several muscle groups. 

The advantages are that the therapist can control the amount of resistance, helpful in early stages where ROM may need to be limited. However, the disadvantages are that there may be difficulty in quantifying the amount of resistance provided (difficult for another therapist to replicate the force on the patient).

Mech. resistance can be applied with many pieces of equipment, from an inexpensive strip of elastic tubing to expensive and highly technological isokinetic equipment. (Weights, exercise machines, and pulley systems are common equipment used).

Core Strengthing:

This refers to the strengthening of the deep postural muscles of the lumbar and cervical spine. It helps to provide stability ot proximal structures, allowing for appropriate movement patterns in body parts farther from the core. Pilates and tai chi emphasize core strengthening during functional movement.

Flexibility:

Decreased flexibility can be a result of musculoskeletal injury including prolonged immobilization and tissue trauma… on the other side, limited flexibility can be a contributor to or a primary cause of the injury.

Soft tissue (muscles0 has the ability to change length or adapt over time with stress. A variety of stretching techniques exists, a stretching technique that works well for one patient may be ineffective for another.

Techniques can be performed passively with an external force applied either manually or mechanically. Stretching can also be performed actively using the contract-relax technique inhibiting the shortened muscle where they actively contract before stretching force is applied.

Balance and Coordiantion:

Balance refers to the ability to maintain body position in equilibrium which require the nervous  and musculoskeletal systems to interact with the environment to control body position. After the injury, if these systems are not properly integrating information, loss of balance and coordination may occur.

Several chemical tests are used to asses a patient’s balance, and numerous excersizes and equipment can be used to facilitate proper balance.

BOSU balance trainer is a popular equipment used. The patient may be progressed from double-leg stance to a single-leg stance. Increase challenge by having patients close theor eyes and by incroporating upper extremity movement with and without weights.

Cardiovascular Endurance Training:

Cardiovascular or aerobic training excersize is performed over a long period of low intensity. Aerobic exercises involve large muscle groups used in a rhythmic type of activity. The PT will choose the most appropriate exercise modality that may include:

• Walking

• Running

• Stair climbing

• Cycling

• Cross-country skiing

• Swimming 

Functional Excersizes:

Incorporate strength, flexibility, balance, and coordination. 

Open kinetic chain exercise is where the end limb segment is free, such as seated leg extension machine. 

Closed kinetic chain exercise is an exercise in which movement at one joint affects movement at other joints.

Particularly important in rehabilitation of the lower extremity since it typically functions with the food on the ground. Are also used with patients with uppe rextremity injuries (shoulder dysfunction).

Aquatic Therapy:

The beneficial effects of aquatic therapy depend largely on the fundamental principles of physics such as buoyancy, viscocity, and hydrostatic pressure of water. Has bot physiological and psychological benefits.

Physiological benefits: improve cardiovascular status, increased muscle strength + flexibility, decreased pain, and improved balance without impact tha toccurs with exercises on land.

Psychological benefits: general relaxation from the warmth of water, th socialization process associated with group sessions, and the increased patient condifednce and level of satisfaction that accompany patinet performance.

Includes but not limited to:

• Treatment

• Rehabilitation

• Prevention

• Health

• Wellness

As well as fitness patients/clients in an aquatic environment with or without use of assistive, adaptive, orthotic, protective, or supportive equipment and devices.

Patient Education:

The therapist and the patient must work as a team and focus on goals and sharing information to acheive optimal results. The PT and PTA are responsible for educating the patient about his or her diagnosis and about:

• excercises to perform at home

• postures + positions to avoid

• strategies to prevent dysfunction from recurring

The therapist must create a treatment atmosphere that takes into account the patient’s values and goals and must also provide encessary nifo in a clear, easily, understood manner. Each patient has a different st of values, differnt expectations, and a different cultural background.

The PT and PTA must treat the whole person rather than just an injured joint.